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Febuxostat and CVD risk. In 2019, the FDA updated their<br />
prescribing information with a boxed warning regarding<br />
an increased risk of all-cause and cardiovascular mortality<br />
with febuxostat. However, the <strong>2020</strong> American College of<br />
Rheumatology gout guidelines now prioritise febuxostat as<br />
the second-line urate lowering treatment over probenecid in<br />
patients without a history of CVD, or if they have significant<br />
renal impairment or urolithiasis. This is based on new data<br />
from a large observational study that did not show an<br />
increased risk of CVD or all-cause mortality with febuxostat. 6<br />
However, given that these recommendations are so recent<br />
they are not yet incorporated into guidance in New Zealand,<br />
and in addition, Special Authority criteria for funded access to<br />
febuxostat still requires that probenecid is trialled first unless<br />
contraindicated.<br />
Benzbromarone should no longer be used<br />
Benzbromarone is a uricosuric medicine that has previously<br />
been prescribed with Special Authority approval to a small<br />
number of patients with gout when other urate-lowering<br />
options were ineffective, not tolerated or contraindicated.<br />
However, as of May <strong>2020</strong>, benzbromarone is out of stock at a<br />
wholesaler level in New Zealand, and PHARMAC has advised<br />
that it will likely delist it from the Pharmaceutical schedule,<br />
although no date is currently set. 14 Therefore, it is now advised<br />
that no newly diagnosed patients should be started on this<br />
medicine, and those currently taking it should change to<br />
another urate-lowering treatment.<br />
Monitoring patients taking urate-lowering<br />
medicines<br />
Once gout is well-controlled with urate-lowering medicines,<br />
reviews should take place regularly every 6–12 months. 8<br />
Patients need to be consistently monitored to: 3<br />
References<br />
1. Winnard D, Wright C, Taylor WJ, et al. National prevalence of gout<br />
derived from administrative health data in Aotearoa New Zealand.<br />
Rheumatology 2012;51:901–9. doi:10.1093/rheumatology/ker361<br />
2. Health Quality & Safety Commission New Zealand. Gout. 2018.<br />
Available from: https://public.tableau.com/profile/hqi2803#!/vizhome/<br />
Goutsinglemap/AtlasofHealthcareVariationGout (Accessed Jul, <strong>2020</strong>)<br />
3. Hui M, Carr A, Cameron S, et al. The British Society for Rheumatology<br />
Guideline for the management of gout. Rheumatology 2017;56:1246.<br />
doi:10.1093/rheumatology/kex250<br />
4. Spencer K, Carr A, Doherty M. Patient and provider barriers to effective<br />
management of gout in general practice: a qualitative study. Ann<br />
Rheum Dis 2012;71:1490–5. doi:10.1136/annrheumdis-2011-200801<br />
5. MacFarlane LA, Kim SC. Gout: a review of non-modifiable and<br />
modifiable risk factors. Rheumatic Disease Clinics of North America<br />
2014;40:581–604. doi:10.1016/j.rdc.2014.07.002<br />
6. FitzGerald JD, Dalbeth N, Mikuls T, et al. <strong>2020</strong> American College of<br />
Rheumatology Guideline for the management of gout. Arthritis Care Res<br />
<strong>2020</strong>;72:744–60. doi:10.1002/acr.24180<br />
7. Janssens HJEM, Fransen J, van de Lisdonk EH, et al. A diagnostic rule for<br />
acute gouty arthritis in primary care without joint fluid analysis. Arch<br />
Intern Med 2010;170:1120–6. doi:10.1001/archinternmed.2010.196<br />
8. Dalbeth N, Winnard D, Gow PJ, et al. Urate testing in gout: why, when<br />
and how. N Z Med J 2015;128:65–8.<br />
9. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidencebased<br />
recommendations for the management of gout. Ann Rheum Dis<br />
2017;76:29–42. doi:10.1136/annrheumdis-2016-209707<br />
10. New Zealand Formulary (NZF). NZF v97. Available from: www.nzf.org.nz<br />
(Accessed Jul, <strong>2020</strong>).<br />
11. Su X, Xu B, Yan B, et al. Effects of uric acid-lowering therapy in<br />
patients with chronic kidney disease: A meta-analysis. PLoS ONE<br />
2017;12:e0187550. doi:10.1371/journal.pone.0187550<br />
12. Perez-Ruiz F, Herrero-Beites AM, Carmona L. A two-stage approach to the<br />
treatment of hyperuricemia in gout: the ‘dirty dish’ hypothesis. Arthritis<br />
Rheum 2011;63:4002–6. doi:10.1002/art.30649<br />
13. Stamp LK, Taylor WJ, Jones PB, et al. Starting dose is a risk factor for<br />
allopurinol hypersensitivity syndrome: a proposed safe starting dose of<br />
allopurinol. Arthritis Rheum 2012;64:2529–36. doi:10.1002/art.34488<br />
14. PHARMAC. Benzbromarone: Discontinuation. Available from: https://<br />
www.pharmac.govt.nz/information-for/enquiries/benzbromaronesupply-issue/<br />
(Accessed Jul, <strong>2020</strong>)<br />
Ensure serum urate levels are achieved and remain below<br />
saturation point<br />
Ensure their renal function has not deteriorated<br />
Encourage ongoing treatment adherence and lifestyle<br />
changes<br />
Manage CVD risk factors, e.g. HbA 1C,<br />
blood pressure<br />
Treat any co-morbidities that may emerge<br />
For the original and extended version of this article<br />
(published as a two-part series) see: “Part 1 – Talking about<br />
gout: time for a re-think” (available at https://bpac.org.<br />
nz/2018/gout-part1.aspx) and “Controlling gout with longterm<br />
urate-lowering medicines” (available at https://bpac.org.<br />
nz/2018/gout-part2.aspx)<br />
www.bpac.org.nz<br />
Best Practice Journal – SCE Issue 1 31
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